**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to insure the services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (Resident #1) of seven residents reviewed for profession standards. LVN B failed to call 911 and failed to immediately notify the physician on [DATE] at approximately 06:20 a.m. when she found Resident #1 in respiratory distress. LVN C failed to follow the NP’s orders to send Resident #1 to the hospital when his oxygen level dropped after he continued to remove his oxygen. The level fell because of his removing the cannula himself. LVN D failed to call 911 after confirming Resident #1 was confused with a low oxygen saturation on [DATE], and being told by LVN C there was an order to send the resident to the emergency room (ER). LVN E failed to call 911 on [DATE] at approximately 11:00 p.m. at change of shift, when LVN C told him Resident #1 had been in respiratory distress during her shift and the NP had ordered the resident be sent to the emergency room (ER), and after observing the resident to be in distress himself at approximately midnight after the shift change. Resident #1 remained in the facility for 4 to 5 hours before being transferred to the hospital when found in his room unresponsive. Resident #1 expired in the emergency room eight minutes after arrival.

The facility failed to monitor LVN C and ensure the NP’s orders were carried out.

These failures could affect residents by placing them at risk of not receiving prompt medical attention based on the orders from the Medical Director or NP.